Tragedy Highlights Critical Gaps in School Trip Safety Training and Risk Management

​In the wake of a recent inquest by the Victorian coroner into the tragic death of Lachlan Cook on an international school tour to Vietnam in 2019 the coroner has shed light on the alarming inadequacies in risk management and decision making of both the school and travel operator.
 
The inquest, conducted by Coroner Audrey Jamieson, highlighted numerous failures and shortcomings on the part of both the school, Kilvington Grammar, and the tour operator, World Challenge. The findings underscore the critical importance of effective training, planning and preparation when running any sort of overseas school trip.
 
Based upon Coroner Jamieson’s findings we’ve reviewed the tragic death of Lachlan Cook in 2019. This is now freely available on our training page.
 
https://training.xcursionsafety.com/courses/lachlan-cook-vietnam-2019
 
Key points from the inquest and our review include:
 
1. Underestimation of Responsibility: The misconception that third-party providers will handle all aspects of safety and medical management can lead to overconfidence and under-preparation on the part of schools. In most countries (incuding Australia), the school remains primarily responsible for the safety and security of the group.
 
2. Lack of Coordination and Communication: A pre-departure meeting involving the school, tour operator, student, and medical team was identified as a missed opportunity to share crucial information about the student's condition and management plan.
 
3. Failure to Carry and Understand Student Medicals: The absence of essential medical documentation on the trip and the failure to involve the school nurse were cited as critical oversights. The coroner highlighted the importance of consulting with medical professionals and parents before international tours.
 
4. Past Performance is No Indicator of Future Success: Are things well run, or are you lucky? Teacher 1 on the program had been on a tour before and it was incident free. Was this due to good planning or pure luck? Luck is not a reliable strategy when it comes to risk management and schools must have clear safety planning and review systems in place.
 
5. Inadequate Training and Experience: The case highlighted the importance of recognizing the limits of training and seeking external support when necessary. In this instance, the adults on the tour lacked the requisite training and experience to identify and address the rapidly growing risks faced by the student.
 
6. Lack of Basic Travel Risk Management: Failure to adhere to standard risk management practices, such as avoiding high-risk activities like eating street food in developing countries, contributed to the tragic outcome. The review emphasizes the institutional responsibility for the well-being of students in such settings.
 
7. Missed Opportunities for Timely Medical Care: Despite ample opportunities to seek medical care, the group pressed on without altering the program when the student's condition deteriorated. The failure to recognize the urgency and act promptly was a significant contributor to the tragedy.
 
8. Fatal Consequences Are Not Isolated: In 2019 alone, there were four student fatalities on international school tours, three of which were due to medical issues. Delayed medical treatment and lack of suitable training of teachers on the program were identified as significant factors in each case.
 
Coroner Jamieson concluded that “the failures and shortcomings of Kilvington Grammar School and World Challenge Expeditions contributed to the death of Lachlan McMahon Cook.” and that his death was preventable.
 
The tragic and preventable death of Lachlan Cook highlights the critical need for schools to properly train all their staff prior to any international trip, so they do have the requisite risk management and decision-making skillset to actually manage the many complex tour risks and care for students – in loco Parenti.